How Can We Prevent School Avoidance and Behavior Problems in Preschool Children?

Data published in the literature agree in showing that at least 5% of children and adolescents in Germany are in need of psychiatric treatment (1). Diagnostic tests and counseling for behavioral abnormalities are indicated in a further 10% to 18% (2, 3). Differences are regularly seen between prevalence figures and the rates of use of support services; the former are always the higher.

Kindergartens and schools as settings for prevention

In this situation, prevention is gaining in importance. Apart from the family, suitable settings for preventive measures are the kindergartens attended by most preschool children, and of course school itself.

Accordingly, the focus of the two studies published in this issue of Deutsches Ärzteblatt International (4, 5) is on interventions carried out in the preschool setting and in schools.

The article by Schell and Albers et al. (4) shows that support programs provided in kindergartens both promote children’s understanding of social problem-solving strategies and lead to improved prosocial behavior. This is significant because even in the preschool age group, prevalence figures of up to 17% have been reported for psychopathological disorders, although in some cases they are only temporary (6).

Early intervention is also important because, without treatment, psychopathological disorders and school avoidance and even delinquency will develop in 5% to 10% of a birth cohort.

This brings us to the second study, by Reissner et al. (5), focusing on interventions in school-age children. The results showed that, although manual-based multimodal treatment (experimental group) did not reduce school-avoiding behavior better than standard treatment in the control group, in both treatment arms the percentage of regular school attendance rose to 60% after 6 months, and this was still maintained a year after the study ended.

Training programs for preschool children

Both studies had a similar design in that each compared an experimental group to a control group receiving “treatment as usual.” The terms “behavioral disorder,” “behavioral problems,” and “inappropriate behavior” are very general and are often used in an inflationary way; they need specification. It is therefore to be welcomed that the aspect addressed by Schell and Albers et al. (4) is affect and emotional regulation and problem-solving behavior in preschool children. Failure to cope with age-typical problems and developmental tasks (7), and a limited ability to react empathetically, are risk factors within the canon of normal development; it is only later that they lead to what is generally referred to as problematic behavior.

This is why it is important that the best way to counter these problematic behaviors (which are mostly of the externalizing type: that is, aggressive behavior, motor restlessness, social behavioral disorders) is by looking at their precursor stages and including these in any preventive measures. The meta-analyses cited in the article by Schell and Albers et al. (4) have shown that social and emotional skills in school-age children can be clearly improved by social training programs, but for preschool children experience is lacking. It is therefore to the credit of these authors that they have successfully expanded the preventive training approach into this group. It will still be important to evaluate whether the effects demonstrated continue to be maintained after the children go on to elementary school.

Interventions for school avoiders

School avoidance and truancy are a serious problem not just nationally in Germany, but internationally, because of their association with a multitude of other burdens, including (8, 9):

• Mental disorders (parents or children)

• Neglect

• Broken family structure

• Drug/alcohol abuse

• Poverty

• Belonging to a minority group

• Being a single parent.

In each case, therefore, the first step before any intervention is careful investigation as to whether the underlying cause is, for example one of the following:

• School phobia (separation anxiety)

• School anxiety (fear of traumatic events at school or on the way to school)

• Truancy (dissocial form of school avoidance).

“School avoidance” is an umbrella term covering a wide variety of collections of symptoms that need different interventions—a fact taken into account in this study (5), in that all patients were recruited from a specialized outpatient clinical service for school-avoiding behavior. The same work group discussed this topic extensively in a review article published several years ago (10).

Global programs

The great importance of the worldwide problem of school avoidance has led to its becoming the focus of the Global Program on Child Mental Health (11), implemented by the World Psychiatric Association (WPA) together with the WHO and the International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP).

In three similar field studies in Brazil, Russia, and Egypt (in [11]), it was shown that targeted interventions (training teachers, counseling of parents, initiatives and structural changes in schools, telephone helplines, individual treatment in problem cases) halved school avoidance rates in the intervention schools within one year compared to the control schools (11).

The message from these studies is that for interventions to be effective, a multifactorial approach is needed that takes into account as many as possible of the conditions and actors involved in the particular problem being addressed.